KAIROS 54RETREAT
PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
Return this form to the Campus Ministry Office by December 13, 2017. Space is limited.
Participant’s Name: ______Grade:______
Birth Date: ______Sex: ______
Parent/Guardian’s name: ______
Home Address: ______
City: ______State:______Zip:______
Home Phone: ______Mom’s Cell: ______Dad’s Cell: ______
I, ______, grant permission for my child, ______,
Parent/Guardian’s NameChild’s Name
To participate in this youth ministry event that requires transportation to a location away from the school site. This activity will take place under the guidance and direction of school employees and/or volunteers from Bishop Manogue Catholic High School. A brief description of the activity follows:
Type of event: Kairos 54Retreat Individual in charge: Matt Galli
Destination of event: Zephyr Point Presbyterian Conference Center Lake Tahoe, Nevada
Estimated time of departure and return:2:30pmSunday,January 28, 2018to 7:00pm Tuesday,January 30th, 2018.
Mode of transportation to and from event: Bus for retreatants and carpool for leaders
Cost: $250 due with permission slip (non-refundable). Make checks payable to BMCHS. Lost Key Fee $35.00.
As parent and/or legal guardian, I remain legally responsible for any actions taken by the above named minor (participant).
I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Bishop Manogue Catholic High School, its officers, directors and agents, and the Diocese of Reno, chaperones, or representatives associated with the event for reasonable attorney’s fees and connections arising in connection therewith.
Signature: ______Date: ______
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.)
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Name & Relationship: ______Phone: ______
Family Doctor: ______Phone: ______
Family Health Plan: ______Policy #:______
Signature: ______Date: ______
Other Medical Treatment: In the event it comes to the attention of the school, its officers, directors and agents, and the Diocese of Reno, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).
Signature: ______Date: ______
Medications: My child is taking medication at present. My child will bring all medications necessary and such medications will be well-labeled. Names of medications and concise directions for seeing that my child takes such medication, including dosage and frequency of dosage, are as follows: ______
Signature: ______Date: ______
No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life threatening and emergency treatment is required.
Signature: ______Date: ______
Or
I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.
Signature: ______Date: ______
Specific Medical Information:The school will take reasonable care to see that the following information will be held in confidence.
Allergic reaction (medications, food, plants, insects, etc,):______
Immunizations: Date of last tetanus/diphtheria immunization: ______
Does your child have a medically prescribed diet or are they vegetarian/vegan? ______
Any physical limitations? ______
Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting? ______
Has child recently been exposed to contagious diseases or conditions, such as mumps, measles, chicken pox, etc.? If so, date and disease or condition: ______
You should be aware of these medical conditions of my child:
______
1